Information on the number, demographics, and geographic distribution of oncologists in the United States comes from the ASCO Workforce Information System (WIS), described in detail in the Appendix A. This section of the report also features information about other disciplines involved in cancer care and examines ways for providers to work across disciplines to deliver seamless, patient-centered care.
Access to Oncologists
In 2015, more than 11,700 hematologists and/or medical oncologists provided patient care to people living with cancer in the United States (Table 3). Although other oncology subspecialities are mentioned in this article, this report primarily focuses on medical oncology and hematology. Medical oncologists treat cancers that occur primarily in body organs and tissues, and hematologists focus on cancers of the blood and other blood diseases.
Estimates from Table 3 come from two data sources: the American Medical Association (AMA) Physician Masterfile and the Centers for Medicare & Medicaid Services (CMS) Physician Compare Dataset.84,85 Because the two datasets account for a similar number of oncologists engaged in patient care (within 1.4% difference for hematologists and oncologists), ASCO draws information from both sources to paint a complete picture of today’s workforce.
The AMA Masterfile identified more than 22,000 oncologists working in the fields of medical oncology and hematology, gynecologic oncology, pediatric hematology and oncology, radiation oncology, and surgical oncology (Table 3). Of these, nearly 19,000 (84.5%) cited direct patient care as their primary professional activity. The remaining 16% spent the majority of their time on administration, research, and teaching, among other activities. A total of 14,215 work in the subspecialties of medical oncology and/or hematology, with 11,894 (83.7%) primarily focusing on patient care. This represents 1.1% growth in the number of hematologists and oncologists engaged in patient care over the past year.
In a similar timeframe, CMS Physician Compare identified approximately 17,800 oncologists providing active patient care, including 11,726 working in hematology or oncology (Table 3). Physician Compare comprises records from all providers who billed for Medicare services within the prior 12 months. Therefore, it does not account for pediatric specialties.
As is true for most of medicine, the aging workforce remains a concern. Among oncologists active in patient care, a growing segment is nearing retirement at age 64 years or older (17.7%).84 Older oncologists continue to outnumber the 13.9% of oncologists younger than age 40 years who have recently entered the field. The median age of oncologists engaged in patient care (51 years) has remained stable over the last few years, although age varies widely by state, with Kansas having the youngest oncologists (median age, 46.5 years) and West Virginia having the oldest oncologists (median age, 57 years; Figure 8). In Delaware, nearly a third (32.1%) of the workforce is nearing retirement at age 64 years or older. Oncologists are not significantly different in age than other types of physicians practicing in the United States (mean 52.6 vs. 52.7 years, p = 0.77).84
Women in Oncology
Overall, women made up 31% of practicing oncologists in 2015. Gynecologic and surgical oncology have higher female participation according to Physician Compare (40% and 37%, respectively), whereas radiation oncology has lower participation (26%). The majority (51%) of pediatric hematologists or oncologists are female according to the AMA. Nearly half (45%) of oncologists younger than age 40 years are women (Figure 9).84 Among hematology and oncology fellowship programs, 46% of trainees are women.86
The physician workforce, and the hematology and oncology workforce in particular, continues to struggle with racial and ethnic minority representation. For example, although the US Census estimates approximately 17% of the population is Hispanic, only 5.8% of practicing oncologists are Hispanic.87,88 In training programs, 5.3% of oncology fellows are Hispanic, whereas 7.6% of all residents and fellows and 7.8% of internal medicine residents are Hispanic (Figure 10A).86 The hematology and oncology field also has lower rates of Hispanics than the other large internal medicine subspecialty fellowships, including cardiology (7.1%), gastroenterology (8.7%), and infectious disease (13%).86 African Americans, despite comprising 13% of the population, represent only 2.3% of practicing oncologists and 3.7% of oncology fellows.86-88 The percentage of all residents and fellows who are African American is 5.7% and the percentage among internal medicine residents is 6% (Figure 10B).86 Among the major internal medicine subspecialty fellows, the hematology and oncology field has the lowest participation of African Americans. These disparities become even more significant as the burden of cancer shifts among racial and ethnic groups, especially in African Americans (Chapter 1).
In a 2015 article titled “Critical Shortage of African American Medical Oncologists in the United States,” study authors note that medical school graduation rates are especially low among African Americans and that the growth rate over time is much slower than among other nonwhite races and ethnicities.89 Recruiting and retaining greater numbers of racial and ethnic minorities in oncology is one essential step towards improving access to highquality, effective, affordable, and compassionate cancer care for the underserved. Collaborative efforts across the entire educational system are needed to boost interest in and exposure to medical professions in diverse populations. Visit www.asco.org/diversity to learn about ongoing ASCO initiatives to enhance diversity in oncology.
Geographic Access to Care
Geographic distribution of US oncologists remains uneven. According to the ASCO’s Workforce Information System, half (50.0%) of hematologists and oncologists practice in eight states: California, New York, Texas, Florida, Pennsylvania, Massachusetts, Ohio, and Illinois (Figure 11A). Together, these states account for 40 million US residents who are 55 years of age or older (the population from which 77% of new cancer cases arise).40 Wyoming has the fewest (n=17) oncologists practicing, and Nevada has the fewest oncologists per 100,000 residents age 55 years or older (Figure 11B). Oncologists are concentrated in metropolitan areas throughout the United States. This presents significant access challenges for the more than 59 million US patients residing in rural areas.90 Although more than 11% of Americans live in rural parts of the country, Physician Compare data show that only 5.6% of oncologists provide service in these areas. Research is beginning to show the effects of geography on cancer outcomes. Geographic disparities in cancer care.
can be particularly pronounced for cancers that benefit from screening and early detection, such as colorectal cancer. A 2015 spatial analysis of county-level colorectal cancer mortality identified three hotspots of high mortality rates: lower Mississippi Delta, west central Appalachia, and eastern North Carolina and Virginia.91 Together, these hotspots spanned more than 200 counties across 12 states. Patients residing in these hotspot areas were 40% more likely to die as a result of their cancer than non-hotspot residents. Although travel distance was found to contribute to these findings, they were largely attributed to differences in racial or ethnic makeup, income, and education. The study authors pointed to screening interventions as a method to reduce the wide variation in cancer outcomes. Another 2015 study of patients with colorectal cancer found that those who travelled longer distances (>50 miles) were less likely to receive adjuvant chemotherapy in accordance with evidence-based guideline recommen-dations.92 In a related analysis, patients with rectal cancer who travelled more than 50 miles for care were less likely to receive of radiation therapy in accordance with guidelines.93
Because cancer care is complex, requires frequent patient visits for treatment and monitoring, and involves providers from many disciplines, geographic access to care may be even more challenging for patients with cancer than for other rurally located patients. In order to address geographic disparities in care, oncology practices are trying new virtual methods of outreach to patients. For example, a recent study of rural patients with hepatocellular carcinoma found that tumor evaluation by virtual tumor board improved the timeliness and comprehensiveness of multidisciplinary evaluation and decreased travel burden.94 Virtual tools and improved care coordination, can expand access to high-quality care for patients living far from major cancer centers.
Other Disciplines with Important Contributions to Cancer Care
From diagnosis to survivorship, cancer care is delivered by health providers from a variety of backgrounds and specialties, including—but not limited to—primary care physicians, urologists, gynecologists, pathologists, pharmacists, genetic counselors, mental health specialists, pain and palliative care specialists, and advanced practice providers. Non-professionals also play a large role, particularly family caregivers.
This new section of the report highlights recent workforce data available on other disciples that contribute to care for people with cancer. This year’s report features recent data on advanced practice providers, genetic counselors, and primary care providers.
Advanced Practice Providers
Advanced practice providers, including nurse practitioners (NPs) and physician assistants (PAs), play important roles in the delivery of cancer care in the United States. Services range from ordering chemotherapy to providing pain and symptom management to organizing or providing routine primary care services for active patients with cancer and survivors. In 2015, US oncology practices reported widespread use of NPs and PAs (Figure 12). Nearly three quarters of ASCO Census practices (73.1%) reported employing advanced practice providers—up substantially from the 52% of 2014 Census practices. Altogether, practices employed a total of 5,419 advanced practice providers (3,913 NPs and 1,506 PAs). The practices with advanced practice providers employed an average of 0.44 advanced practice providers per oncologist.
To better understand the significant contributions made by advanced practice providers working in oncology, ASCO is partnering with other professional societies to investigate the size and nature of the advanced practice provider workforce in oncology, as well as to catalogue the range of services provided. Results will be available in 2017.
As noted earlier, there is growing emphasis on precision medicine and the genetic testing that identifies patients who can benefit from targeted therapies. Genetic counselors play a key role in explaining implications and results of genetic testing to healthy individuals and patients with cancer . Traditionally, genetic counselors have focused on hereditary characteristics that put people at higher risk of developing cancer. With greater understanding of cancer development at the molecular level, genomic tests to identify alterations within a cancer cell, and drugs that target these alterations, genetic counselors play an increasingly important role in helping patients and oncologists understand treatment options.
Access to genetic counselling is an important part of patient-centered cancer care, however, the supply of these professionals is limited. The American Board of Genetic Counseling certified 3,766 genetic counselors in 2014, of whom 18% practiced in oncology.95 By this estimate, approximately 680 genetic counselors were available throughout the country to treat patients in a cancer care setting.
To expand the reach of this limited workforce, some oncology practices are leveraging telemedicine to provide access to genetic counseling. For instance, recent demonstration projects in Idaho, Maine, and North Carolina revealed that cancer genetic counseling telemedicine initiatives can lower costs, add convenience for patients, and maintain high patient satisfaction.96-98
Primary Care Providers
Primary care providers are often the first to detect a patient’s cancer and are involved in a patient’s care long after completion of active cancer treatment. However, a recent study revealed that some primary care providers feel unprepared to care for cancer survivors.99 Moreover, the US primary care workforce is facing a well-documented shortage that is expected to worsen in the wake of the Affordable Care Act. In 2013, for instance, the National Center for Health Workforce Analysis (part of the US Department of Health and Human Services) projected a shortage of as many as 20,400 primary care physicians by 2020.100
To help care teams provide seamless, patient-centered care to patients transitioning out of active treatment, ASCO partnered with two primary care organizations—the American Academy of Family Physicians and the American College of Physicians—in planning an inaugural Cancer Survivorship Symposium. The symposium took place from January 15 to 16, 2016, in San Francisco, California. Visit www.asco.org/survivorship for more information on the ASCO activities surrounding survivorship care.
ASCO will continue to monitor workforce studies and initiatives across disciplines in an effort to better understand the workforce available to meet the needs of people with cancer. This will enable the Society to identify opportunities to collaborate with other healthcare professions to help ensure delivery of coordinated care.
Inter-professional Education and Practice The increasing demand for cancer and other healthcare services brought on by the growing and aging population is straining the healthcare workforce at large. New methods of care delivery, including team-based care and smarter use of technology, will be essential to meeting demand in future years. Collaborative care enabled by technology can improve both quality and efficiency of cancer care; it can also enhance patient-centered care, delivering services necessary from the patient standpoint, not from that of the physician or medical specialty. In 2015, the Institute of Medicine published a report, Measuring the Impact of Interprofessional Education (IPE) on Collaborative Practice and Patient Outcomes, which called for better alignment between health professional training and collaborative practice—particularly in this time of health system redesign.101 In order to deliver seamless, patient-centered care, oncology providers from all disciplines must work together. Better care coordination can be achieved by: (1) improving the oncology training environment to reflect team-based practice, (2) continuing education among individuals currently in the workforce, and (3) redesigning practices and health systems to provide integrated care.
Recognizing the importance of inter-professional training, the Accreditation Council of American Medical Graduates requires of hematology and medical oncology fellowship programs that fellows “work in inter-professional teams to enhance patient safety and improve patient care quality.”102 A recent article highlighted the development of a geriatric oncology curriculum by a team comprising a geriatrician, a medical oncologist, an oncology pharmacist, a nurse practitioner, and two oncology chief fellows.103 The curriculum is currently in pilot testing, with evaluation in place to focus on three areas of educational need: geriatric assessment, pharmacology, and psychosocial knowledge skills. Demonstration projects such as this will be important as graduate medical training moves in this direction.
In oncology practice, formal efforts are taking place to educate providers in team-based care. In 2014, the Agency for Healthcare Research and Quality funded Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as an evidence-based repository of tools available to practices to improve communication among multidisciplinary teams. Some oncology practices have begun to implement TeamSTEPPS, although evaluation results are not yet available. In another example, an academic practice in South Carolina implemented a multidisciplinary breast clinic model and found patients to be highly satisfied with the care they received.104 It also identified quality improvement targets for the clinic such as increased emphasis on provider communication about psychosocial issues.
In 2015, ASCO partnered with the National Cancer Institute to launch Teams in Cancer Care Delivery to apply the science of team-based care to oncology (Box 5).
The concept of integrated care is also penetrating the oncology community. Recently, the World Health Organization offered the following working definition for integrated care as it pertains to management of complex, chronic disease: “Initiatives seeking to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care.”105 The Veterans Administration and Kaiser Permanente are two large scale examples of integrated care systems active in the United States. At the 2015 ASCO Annual Meeting, Harvard Business School professor Dr Michael Porter described the integrated care unit, a model of care with the following key attributes:106,107
- Organized around the patient medical condition or set of closely related conditions.
- Involves a dedicated, multidisciplinary team that devotes a significant portion of time to the condition.
- Providers involved are members of or affiliated with a common organizational unit.
- Takes responsibility for the full cycle of care for the condition, encompassing outpatient, inpatient, and rehabilitative care as well as supporting services (e.g., nutrition, social work, and behavioral health).
- Incorporates patient education, engagement, and follow up as integral to care.
- Uses a single administrative and scheduling structure.
- Co-located in dedicated facilities.
- Care is led by a physician team captain and a care manager who oversee each patient’s care process.
- Measures outcomes, costs, and processes for each patient using a common information platform.
- Providers function as a team, meeting formally and informally on a regular basis to discuss patients, processes, and results.
- Accepts joint accountability for outcomes and costs.
Dr Porter demonstrated the application of the integrated practice unit in head and neck cancer, where a patient would visit a head and neck center for his or her major point of care. This center would provide easy access to the many providers and services needed for that patient, including medical, surgical, radiation, and dental oncologists, as well as pathologists and speech and swallowing specialists. The center would also facilitate access to primary care, social work, smoking cessation, plastic surgery, and other services essential to head and neck cancer care throughout its full continuum. Establishing such a system, argued Dr Porter, would help economize care delivery while also focusing care on outcomes important to the patient.106
As multidisciplinary care expands in the coming years, it will be increasingly important to monitor logistic toxicities experienced by patients attempting to navigate their cancer care.108 Logistic toxicities refer to administrative burdens borne by patients and can include processing medical bills and completing insurance paperwork. Such responsibilities may lose precedence in the wake of active cancer treatment, especially as patients juggle recurring appointments with multiple providers.
ASCO and National Cancer BOX 5 Institute Teams in Cancer Care Delivery
ASCO and the National Cancer Institute have formed a collaboration to investigate team practice arrangements in oncology, aiming to serve the following goals:
1. Bring together scientists and clinicians working on issues relevant to the effectiveness of teams involved in cancer care delivery in order to inform the research agenda for teamwork, team effectiveness, and team performance in an oncology care setting and an era of health reform
2. Provide the clinical oncology community with practical strategies for how to organize effective healthcare teams
3. To identify areas to build the foundation for team research in cancer care delivery, such as taxonomy, operational definitions, and measurement
Clinicians, researchers, and patients will author manuscripts and presentations involving concepts of team-based care and clinical scenarios addressing a point in the cancer continuum, evidence-based concept, and cancer type. In September 2015, 23 teams were selected to participate in the project. Results of their work will be presented during a February 2016 conference, with accompanying papers published in the Journal of Oncology Practice.
For more information, visit www.asco.org/teams
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